CHOW Rules (42 C.F.R and related manual provisions) apply to:

Transcription

1 Healthcare Transactions & Medicare s Change of Ownership (CHOW) Rules AHLA Medicare & Medicaid Payment Institute March 20 22, 2013 Baltimore, MD Jan M. Lundelius, Esquire * Assistant Regional Counsel Office of the General Counsel U.S. Dep t of Health and Human Services Philadelphia * The views expressed herein are those of the author and do not necessarily reflect the official policy or position of the U.S. Department of Health & Human Services, the Office of the General Counsel, or the Centers for Medicare & Medicaid Services. 1 CHOW Rules (42 C.F.R and related manual provisions) apply to: All providers (42 C.F.R ): e.g., Hospitals (including critical access hospitals and long term care hospitals). Hospices Skilled nursing facilities Home health agencies CHOW processing is necessary for supplier participants that have category specific agreements with the Secretary (or that must file cost reports). SOM A. Rural Health Clinics 42 C.F.R Ambulatory Surgical Centers 42 C.F.R., Part 416, Subpart C. Federally Qualified Health Centers, 42 C.F.R., Part 491; 42 C.F.R End Stage Renal Disease Facilities 42 C.F.R

2 I. Is the Change a CHOW Situation? II. The Benefits and Burdens of Accepting Automatic Assignment of the Existing Medicare Provider Agreement. III. The Benefits and Burdens of Refusing Automatic Assignment of the Existing Medicare Provider Agreement. IV. All Acquisition/Combinations of Providers Require a Decision by the Buyer to Accept or Refuse Assignment of the existing Provider Agreement. 3 I. Is the Change a CHOW Situation? (Did the responsible legal entity change?) 4 2

3 Examples of CHOW Situations A corporation acquires all or most of the (providerrelated) assets from another corporation. A provider corporation acquires the assets of another provider, intending to establish the acquired assets as provider based to the provider it already owns. For example, the owner of Hospital A acquires Hospital B, and wants it to be a provider based psychiatric wing of Hospital A. This is a CHOW situation, because the acquiring entity must decide whether to accept or refuse assignment of Hospital B s existing Medicare provider agreement. 5 Examples of CHOW Situations A merger or consolidation of two corporations which results in a different legal entity being ultimately responsible for care at the provider. 42 C.F.R (a)(3). Example: Corporation X owns a Medicare provider. Corporation X merges into corporation Y. This is a CHOW, because Y replaces Corporation X as the corporate entity responsible for care at the provider. Example: Corporation X owns a Medicare provider. Corporation X and Corporation Y are consolidated into Corporation Z. This is a CHOW, because Corporation Z replaces Corporation X as the corporate entity responsible for care at the provider. The lease of all or part of a provider facility constitutes change of ownership of the leased portion. 42 C.F.R (a)(4). Example: Corporation X owns both a Medicare skilled nursing provider and the building in which care is provided. Corporation X sells the Medicare provider to Corporation Y, but continues to own the building, and leases it to Corporation Y. This is a CHOW, because Corporation Y replaces Corporation X as the corporate entity responsible for care at the provider. 6 3

4 Transactions which are not CHOWs for Survey and Certification Purposes When the responsible legal entity does not change, there is no CHOW: Stock transfer (but see 42 C.F.R for enrollment provisions governing home health agencies undergoing a change in majority ownership). The merger of Corporation A (which does not own a provider) into Corporation B, which owns a provider. There is no CHOW, because Corporation B remains responsible for care at the provider. 42 C.F.R (a)(3). 7 CHOW = Automatic Assignment of the Existing Provider Agreement In a CHOW, the existing provider agreement is automatically assigned to the new owner. 42 C.F.R (c). Conditions that apply to assigned agreements. An assigned agreement is subject to all applicable statutes and regulations and to the terms and conditions under which it was originally issued including, but not limited to, the following: (1) Any existing plan of correction [or outstanding citations]. (2) Compliance with applicable health and safety standards. (3) Compliance with the ownership and financial interest disclosure requirements. (4) Compliance with civil rights requirements. 42 C.F.R (d). 8 4

5 Refusing Automatic Assignment = Voluntary Termination CMS policy permits a new owner to refuse automatic assignment of the provider agreement. SOM A. This is not a CHOW, since there is no automatic assignment of the existing provider agreement. Refusal of automatic assignment means that the existing provider agreement terminates effective with the date ownership changes. SOM A, 75 Fed. Reg. 50,042, 50,401 (Aug. 16, 2010). CMS treats this as a voluntary termination under 42 C.F.R II. The Benefits and Burdens of Accepting Automatic Assignment of the Existing Provider Agreement. 10 5

6 Main Benefits of Automatic Assignment No break in Medicare participation (no survey required for continued Medicare participation). Provider receives any underpayments (including those related to reimbursement appeals), even if they relate to the pre transfer period. Medicare Financial Management Manual, CMS Publication , Chapter 3, 130 (FMM). 11 Main Benefits of Automatic Assignment Hospital IPPS excluded statuses continue (as long as other requirements are met see 42 C.F.R ), including: Psychiatric Hospital (entire hospital or unit); Rehabilitation Hospital (entire hospital or unit); Children s Hospital Cancer Hospital Long Term Care Hospital 12 6

7 Main Benefits of Automatic Assignment Special payment treatment/classifications continue (as long as other requirements are met), including (all in 42 C.F.R, Part 412): Sole Community Hospital Rural Referral Center Medicare Dependent Hospital Renal Transplant Centers Geographic reclassifications Indirect Graduate Medical Education Costs Disproportionate Share Hospitals Essential Access Community Hospitals Main Benefits of Automatic Assignment Provider Based Status or Medicare Relationships Retained 42 C.F.R ; For hospitals and CAHs, if a new owner acquires the provider and accepts assignment of the provider agreement (and does not seek to combine it with another hospital), it will retain the provider based status of: Provider based RHC Hospital based ESRD Hospital operated ASC 14 7

8 Main Benefits of Automatic Assignment Data for IPPS calculation retained: To calculate Medicare Disproportionate Share Hospital (DSH) payment. 42 C.F.R To calculate charge to cost ratios (CCRs) for outlier payment. 42 C.F.R (i)(3)(i). Retention of IPPS base period for payment and cost reporting history. 42 C.F.R., Part 412. GME residency slots retained. 42 C.F.R (h)(2). Wage index reclassification retained. 42 C.F.R Electronic Health Record Incentive Payment. 42 C.F.R (c). 15 Main Benefits of Automatic Assignment Grandfathering retained, including: Hospital within a hospital 42 C.F.R (f). Satellite 42 C.F.R (h), (e). Provider based 42 C.F.R (b)(2), (b)(5). CAH necessary provider determinations 42 C.F.R (c). CAH co location 42 C.F.R (e). CAH provider based distance from another hospital 42 C.F.R (e). 16 8

9 Main Burdens of Automatic Assignment The new owner is responsible for the former owner s Medicare liabilities, including any Medicare overpayments. SOM B1. Because the provider remains the same, Medicare payments to the provider will continue to be adjusted to account for prior overpayments under 42 U.S.C. 1395g(a), including those relating to pre CHOW periods. With assignment, the new owner assumes... the repayment of any accrued overpayments, regardless of who had ownership of the Medicare agreement at the time the overpayment was discovered. FMM Chapter 3, 130. The new owner will be responsible for the quality history of the provider and any unpaid civil money penalties resulting from quality of care deficiencies. 17 Transfer/Sales Agreement Can Reduce or Eliminate CHOW Financial Burdens The parties agreement: Can provide for the seller to indemnify the buyer for pre CHOW overpayments, see FMM, Chapter 3, 130. Alternatively the agreement can provide that some of the purchase price be placed into escrow pending resolution of pre transfer cost years. Can provide for buyer to pay pre CHOW underpayments to seller. Id. 18 9

10 Transfer/Sales Agreement Can Reduce or Eliminate CHOW Financial Burdens The parties agreement: Should not purport to sell the provider agreement or CCN, which are not the property of the owner. SOM E. Clauses that purport to sell Medicare assets without Medicare liabilities are not binding on CMS. FMM Chapter 3, Payment During CHOW Processing A CHOW is effective at 12:01 a.m. on date of transaction. SOM 32101E. In a CHOW, no payment goes to the new owner s bank account until the contractor receives and implements the tiein notice confirming that CMS has approved the CHOW. Until that process is complete, payments to the provider will continue to go to the prior owner s bank account. See PIM If the new owner wants all payments for services it provides after the CHOW date to go to its own bank account, it bills only after CMS notifies it that the CHOW processing is complete. CMS strongly encourages providers to use this process. See PIM

11 Payment During CHOW Processing However, in their sales or other transfer agreement, the parties may provide that the new owner will bill during the CHOW processing period. In that case, payments will continue to go to the prior owner's bank account until CHOW processing is complete. It is up to the parties to ensure the proper distribution of these payments during the CHOW processing period. The new owner proceeds at its own risk if it decides to bill during the CHOW processing period. The parties' agreement cannot change CMS procedures. CMS is not responsible for enforcing the agreement of the parties as to the ultimate distribution of payments during the processing period, and will not change its standard procedures to effectuate the terms of any such agreement. 21 III. The Benefits and Burdens of Refusing Automatic Assignment of the Existing Provider Agreement

12 Main Benefits of Refusing Automatic Assignment Because the new owner applies for initial certification to the Medicare program and obtains a new provider agreement: It is not responsible for overpayments which were made to the prior provider. FMM Chapter, 130. The new owner does not have the quality history associated with the provider agreement it refuses. 23 Main Burdens of Refusing Automatic Assignment Break in Certification CMS policy permits a new owner to refuse automatic assignment of the provider agreement. SOM A. This is not a CHOW, since there is no automatic assignment of the existing provider agreement. Refusal of automatic assignment terminates the existing provider agreement effective with the date ownership changes. SOM A, 75 Fed. Reg. 50,042, 50,401 (Aug. 16, 2010). CMS treats this as a voluntary termination under 42 C.F.R

13 Main Burdens of Refusing Automatic Assignment Refusing assignment terminates the existing provider agreement and CMS Certification Number (CCN) (formerly know as the provider number ). SOM A Deemed Medicare certification status for that location/facility is lost. All special payment statuses terminate. All grandfathering statuses are lost (e.g., hospital within a hospital). 25 Main Burdens of Refusing Automatic Assignment Break in Certification No survey can take place until after: (1) the former owner s provider agreement is terminated; (2) the new owner has ownership and control of the facility; and (3) the Medicare Administrative Contractor recommends the initial 855 for approval. See also 75 Fed. Reg. 50,042, 50, (Aug. 16, 2010); Survey and Certification Memorandum S&C at 11 (10/17/08). If the survey determines condition level noncompliance, that survey cannot be used to establish the effective date of Medicare participation. 42 C.F.R (a), (a)

14 Main Burdens of Refusing Automatic Assignment Break in Certification If the new owner wants the facility/location to participate in Medicare, it must file for initial certification, and meet all current requirements for any special status. 75 Fed. Reg. 50,042, 50,401 (Aug. 16, 2010). The new provider is not eligible for Medicare payments for services it provides before the date that the provider meets all Medicare requirements (as determined by CMS Regional Office). See also 42 C.F.R In this situation, Medicare will never pay the provider for services it provides before the date on which the provider qualifies as an initial applicant. 75 Fed. Reg. 50,042, 50,401 (Aug. 16, 2010). 27 Main Burdens of Refusing Automatic Assignment Hospital IPPS excluded statuses terminate for the entire hospital and for hospital units, including: Psychiatric Hospital (entire hospital or unit) Rehabilitation Hospital (entire hospital or unit) Children s Hospital Cancer Hospital Long Term Care Hospital 28 14

15 Main Burdens of Refusing Automatic Assignment Special payment treatment/classifications terminate, including: Sole Community Hospital status Rural Referral Center status Medicare Dependent Hospital Transplant Center Certification Geographic reclassifications. Indirect Medical Education Costs Disproportionate Share Hospitals 29 Main Burdens of Refusing Automatic Assignment Provider Based Status or Medicare Relationships Terminate 42 C.F.R ; Provider based RHC Hospital based ESRD Hospital operated ASC 30 15

16 Main Burdens of Refusing Automatic Assignment Former provider s data irrelevant to IPPS calculation: To calculate Medicare Disproportionate Share Hospital (DSH) payment. To calculate charge to cost ratios (CCRs) for outlier payment. Retention of IPPS base period for payment and cost reporting history. GME residency slots retained. Wage index reclassification retained. Electronic Health Record Incentive Payment. 31 Main Burdens of Refusing Automatic Assignment Grandfathering terminates, including: Hospital within a hospital Satellite Provider based Start whole hospital exception CAH necessary provider determinations CAH co location CAH provider based distance from another hospital 32 16

17 Effective Date for Initial Certification After Refusing Automatic Assignment Prospective provider must meet all Medicare requirements. 42 C.F.R The onsite full initial survey is usually the final federal requirement completed. New owners should not count on obtaining Medicare certification effective on the date of the first initial survey. 33 Effective Date for Initial Certification After Refusing Automatic Assignment (Non SNFs) If all other federal requirements for Medicare participation have been met, the effective date of Medicare participation will be: If the prospective provider is in full compliance (no citations of noncompliance), then its effective date of certification will be the date of the survey. 42 C.F.R (b)

18 Effective Date for Initial Certification After Refusing Automatic Assignment (Non SNFs) If the prospective provider has only standard level deficiencies, then its effective date will be the date on which CMS receives an acceptable Plan of Correction (POC). 42 C.F.R (c)(2), see SOM 2728 re: POCs. If CMS determines that the provider s POC is not acceptable, the prospective provider will revise and resubmit the POC. SOM 2728E. The effective date will be the date on which CMS or the State survey agency receives a POC that is determined to be acceptable. SOM 2016E, 2728B. 35 Effective Date for Initial Certification After Refusing Automatic Assignment (Non SNFs) If the prospective provider has condition level citations: The survey cannot be used to establish the effective date of Medicare participation. 42 C.F.R (a). If condition level deficiencies exist, the regulations do not permit initial certification based on a Plan of Correction. National Hospital for Kids in Crisis, DAB No at 10 (1996); Ultra X Imaging, DAB CR2066 at 2 (2010). CMS will issue a denial letter. SOM 2005A2. The prospective provider may appeal this denial. 42 C.F.R (b),(c)

19 Effective Date for Initial Certification After Refusing Automatic Assignment (Non SNFs) Condition Level Citations Once the prospective provider has implemented systemic corrections, it must reapply for certification. SOM 2005.A2. If the State agency surveys the applicant within three months of the date of the denial letter, then the enrollment process does not have to be repeated. SOM 2005.A2. This will be a new initial survey (also called a resurvey ) of all applicable Conditions of Participation (which is not the same as a revisit survey). See Big Bend Hospital Corp., DAB No at 23 (2002), aff d, Big Bend Hospital Corp. v. Thompson, 88 F.App x 4 (5 th Cir. 2003). 37 Effective Date for Initial Certification After Refusing Automatic Assignment (SNFs) The effective date of initial certification is the date on which the SNF is in substantial compliance with the requirements for participation. 42 C.F.R (c)(1), If the skilled nursing facility is in substantial compliance, the State certifies and recommends that the regional office and/or State Medicaid Agency enter into an agreement with the facility. SOM

20 Effective Date for Initial Certification After Refusing Automatic Assignment (SNFs) If the initial survey of prospective provider finds noncompliance at the D or E level, or the F level without substandard quality of care, the State survey agency may accept written evidence of correction to confirm substantial compliance in lieu of an onsite revisit. However, the State survey agency always has the discretion to conduct an onsite revisit to determine if corrections have been made. If the noncompliance is at the F level with a finding of substandard quality of care, or above, the State survey agency must conduct an onsite revisit to determine substantial compliance after the facility submits an acceptable POC. SOM CMS Has the Authority to Validate Survey Results [T]he statutory and regulatory scheme reserves an inherent authority in CMS to take steps to assure itself that a prospective provider is able to comply with the requirements in place to protect patients before making a determination on a certification recommendation. See Big Bend Hospital Corp., DAB No at 9 (2002), aff d, Big Bend Hospital Corp. v. Thompson, 88 F. App x 4 (5 th Cir. 2003). CMS makes an independent determination to either grant or deny the application for Medicare certification. See 42 U.S.C. 1395aa(a) ( To the extent that the Secretary finds it appropriate, an institution or agency which such a State (or local) agency certifies is a hospital, skilled nursing facility, rural health clinic, comprehensive outpatient rehabilitation facility, home health agency, or hospice program )

21 CMS Has the Authority to Validate Survey Results If CMS has concerns about the reliability of a survey by conducted by a State survey agency, an approved accrediting organization, or a contract survey team, it may conduct a comparative survey within 60 days of the state survey to assess the State survey agency s performance in the interpretation, application, and enforcement of Federal requirements. SOM 4157.D1. See Big Bend Hospital Corp., DAB No at 2, 7, n.2 (2002), aff d, Big Bend Hospital Corp. v. Thompson, 88 F. App x 4 (5 th Cir. 2003). Concerns which might trigger a validation/comparative survey include: Not all applicable CoP were surveyed. Inadequate sample size Not a full survey of all provider locations Citations do not reflect the facts recorded in the survey report. The survey was not unannounced (i.e., the day of or very soon after the effective date of acquisition). 42 C.F.R , 488.4, 488.6, (c)(4); SOM Appendices. 41 IV. Acquisition/Combinations of Providers Require Decision on Accepting or Rejecting Provider Agreement

22 NOTE: For Certification Purposes, the Terms Merger and Consolidation Apply only to Corporations The survey and certification regulation at 42 C.F.R (a)(3) states that the merger or consolidation of two corporations which results in a different entity being ultimately responsible for care at the provider is a CHOW. The definitions of the terms: (1) Standard CHOW; (2) Consolidations; and (3) Acquisition/Merger in the Medicare in of the PIM are "for purposes of provider enrollment only. The PIM recognizes that Changes of ownership (CHOWs) are officially defined and governed by 42 CFR and Publication , chapter 3, 3210 through (C). The ROs [survey and certification staff] make the final determination as to whether a CHOW has occurred (unless this function has been delegated). PIM Combining Acquired Provider B With Currently Owned Provider A Under A s Medicare Provider Agreement/CCN For certification purposes, whenever a new owner acquires a Medicare certified provider, the provider agreement is automatically assigned unless the new owner affirmatively refuses assignment. SOM This rule applies equally when the owner of a provider seeks to combine an acquired provider with its existing provider under the existing provider s provider agreement/ccn. This rule applies regardless of how the transaction is described, e.g., an acquisition/merger; adding a new campus, practice location or satellite location to Provider A; acquiring Provider B s assets and operating them as part of Provider A; seeking a Medicare subprovider CCN, etc

23 Provider A s Owner Accepts Assignment of Acquired Provider B s Provider Agreement. All the benefits of a CHOW apply. No break in Medicare participation (the approved accrediting organization for both providers may extend Medicare deemed status). Special payment statuses and grandfathering continue (as long as other conditions are met). After CHOW & merger, Hospital B s agreement is subsumed and its CCN is retired. Note: there cannot be a CHOW when a new owner purchases a unit of a hospital (e.g., seeking to buy its excluded status), because a hospital unit does not have its own provider agreement which can be assigned. In this situation, the new owner must seek initial certification for the unit. 45 Provider A s Owner Refuses Assignment of Acquired Provider B s Provider Agreement. The existing provider agreement terminates; and any deemed status is lost. That facility/location is no longer eligible for Medicare payment for any services it provides (and cannot later bill for those services) The new owner cannot bill for services at the acquired facility/location B using Provider A s provider number or NPI

24 Provider A s Owner Refuses Assignment of Acquired Provider B s Provider Agreement The new owner must apply for initial certification of the acquired location. The State survey agency or approved accrediting organization (AO) cannot take action to schedule an initial certification survey to determine that the facility/location meets all applicable Conditions of Participation at the acquired campus until after: The effective date of the acquisition, and The MAC notifies the RO that the initial 855 is recommended for approval. 47 Provider A s Owner Refuses Assignment of Acquired Provider B s Provider Agreement When the new owner rejects assignment of the existing provider agreement and that agreement terminates, the AO may NOT extend deemed status of acquired facility/location through the termination. The AO also may not extend the deemed status from Provider A to the acquired facility/location

25 Neither Contractors nor Accreditation Agencies Ever Have Authority to make CHOW or other Certification Decisions. "The RO (this refers to the CMS Regional office survey and certification staff) has the delegated authority for making the determination if a CHOW actually exists.... Upon review of all documents, the RO will make the decision as to whether or not a CHOW has occurred. SOM 2005E1. Although this provision also states that the RO may delegate this responsibility to the State survey agency, I am aware of no such delegation at this time. 49 Survey and Certification Memorandum (10/17/08) If a Medicare participating hospital... whether deemed or non deemed, acquires a provider that already participates in Medicare but does not assume that provider s Medicare provider agreement, then a survey of the new location is required after the acquisition and before payment for services begins at the new location. In such a case involving acquisition by an accredited, deemed provider without assumption of the provider agreement, an AO [accrediting organization] may not extend the new owner s deemed status accreditation to the newly acquired facility. Survey and Certification Memorandum S&C at 11 (10/17/08) er09 08.pdf 50 25

26 Mission Regional Hospital Medical Center DAB CR1248 (2011) (Facts) Petitioner owned a Medicare certified acute care hospital (Mission Viejo). On 6/30/09, petitioner acquired assets of a second Medicare certified acute care hospital, South Coast Medical Center (South Coast), located in Laguna Beach. Before the acquisition date, Petitioner submitted an 855A to its MAC to add South Coast as a new practice location effective July 1, Mission Regional Hospital Medical Center DAB CR1248 (2011) (Fact) Petitioner then sought to treat the Laguna Beach facility as a separate campus of Mission Viejo, and billed for services rendered at the Laguna Beach location under Mission Viejo s Medicare provider number effective on the acquisition date. South Coast submitted an 855A that reported its acquisition by Mission. It appeared that South Coast was voluntarily terminating its provider agreement

27 Mission Regional Hospital Medical Center DAB CR1248 (2011) (Facts) Petitioner expressly declined to assume the liabilities under South Coast s existing Medicare provider agreement. On February 10, 2010, CMS notified petitioner that, since it did not assume the existing provider agreement, the agreement was voluntarily terminated. CMS stated that the new owner could not bill for services at the new location until the State survey agency or AO completed a Medicare certification survey, and CMS determined that all applicable Medicare requirements had been met. 53 Mission Regional Hospital Medical Center DAB CR1248 (2011) (Facts) The AO completed a survey for the Laguna Beach campus effective March 18, CMS advised that the effective date of the new Laguna Beach campus for certification and reimbursement was March 18, The owner was not entitled to Medicare payment for any services provided at the Laguna Beach location between 7/1/09 and 3/18/

28 Mission Regional Hospital Medical Center DAB CR1248 (2011) (ALJ Decision) Grants summary judgment to CMS. Cites S&C Letter and preamble to revised 42 C.F.R , quoted above. Rejects arguments that statements by contractor are binding. Petitioner s argument amounts to a claim of equitable estoppel. Federal case law and Board precedent establish: (1) estoppel cannot be the basis to require payment of funds from the federal fisc; (2) estoppel cannot lie against the government, if at all, absent a showing of affirmative misconduct, such as fraud; and (3) I am not authorized to order payment contrary to law based on equitable grounds. 55 Mission Regional Hospital Medical Center DAB No (May 21, 2011) (Appellate Division) Upholds ALJ s grant of summary judgment to CMS. Appellate Decision at 1. Because Mission did not assume the provider agreement, it did not take automatic assignment. Id. at 6. Mission did not dispute that the provider agreement did not transfer over. Id

29 Mission Appellate Decision There was no longer a provider agreement covering the Laguna Beach campus as of July 1, Therefore, Mission could not obtain Medicare billing privileges for the Laguna Beach campus merely by submitting an enrollment application seeking to add it as a new practice location. It could bill for the Laguna Beach Campus only after going through the survey and certification process. Id. 57 Notification for Certification Purposes The new owner should notify the CMS regional office, survey and certification branch, 45 days in advance, whether it will accept automatic assignment (CHOW) or refuse it (termination). 42 C.F.R (b), ; SOM B1. The new owner should indicate on the 855A that this is a CHOW, and that it is accepting or refusing assignment of the existing provider agreement, so that the enrollment documentation is consistent with the certification documents. NOTE: There are also enrollment requirements for CHOW and termination notification. See regulations at 42 C.F.R. Part 424, and the Program Integrity Manual

30 CONCLUSION Automatic Assignment was created to benefit providers. I personally recommend spending your time formulating a contract that properly apportions financial obligations and benefits between the parties, rather than taking the risk of trying to have it both ways. 59 CONTACT INFORMATION Jan M. Lundelius, Esquire Assistant Regional Counsel Office of the General Counsel U.S. Dep't of Health and Human Services, Region III Suite 418 The Public Ledger Building 150 S. Independence Mall West Philadelphia, PA Phone: (215) Fax: (215) E mail: jan.lundelius@hhs.gov 60 30